CHRIST-RICE COUNSELING & CONSULTING (CRCC)
Client History and Information
Basic Information:
Date:
Name:
Social Security Number:
Date of Birth:
Gender: [ ] Male [ ] Female [ ] Other
Ethnicity:
Home Address:
Home Phone Number: May we leave a message? [ ] Yes [ ] No
Work Phone Number: May we leave a message? [ ] Yes [ ] No
Mobile Phone Number: May we leave a message? [ ] Yes [ ] No
If the above client is a minor complete the following:
Name of Guardian:
Address of Guardian:
Guardian’s Home Phone: May we leave a message? [ ] Yes [ ] No
Guardian’s Work Phone: May we leave a message? [ ] Yes [ ] No
Guardian’s Mobile Phone: May we leave a message? [ ] Yes [ ] No
**If you would like to bill your insurance for your sessions or a portion of the cost, you can request the necessary documentation to submit to your insurance company.
Referral Source
Who referred you to our office, or how did your learn about our practice?
Emergency Contact Information
In case of an emergency, who should we contact?
Name:
Relationship:
Address:
Phone Number:
History Information
Who is providing the history information?
[ ] The patient [ ] The patient’s guardian [ ] Other
Please describe the current complaint or problem as specifically as you can, in your own words.
How long have you experienced this problem, or when did you first notice it?
What stressors may have contributed to the current complaint or problem?
Check all words/phrases that describe what you are experiencing and explain if possible.
[ ] Substance abuse/dependence
[ ] Addiction (internet, porn, shopping, exercise, gaming, gambling, etc.
[ ] Depression/Sad/Down feelings
[ ] High/Low energy level
[ ] Angry/Irritable
[ ] Loss of interest in activities
[ ] Difficulty enjoying things
[ ] Crying spells
[ ] Decreased motivation
[ ] Withdrawing from people/Isolation
[ ] Mood Swings
[ ] Black and white thinking/All or nothing thinking
[ ] Negative thinking
[ ] Change in weight or appetite
[ ] Change in sleeping pattern
[ ] Suicidal thoughts or plans/Thoughts of hurting yourself
[ ] Self-harm/Cutting/Burning yourself
[ ] Homicidal thoughts or plans/Thoughts of hurting others
[ ] Poor concentration/Difficulty focusing
[ ] Feelings of hopelessness/Worthlessness
[ ] Feelings of shame or guilt
[ ] Feelings of inadequacy/Low self-esteem
[ ] Anxious/Nervous/Tense feelings
[ ] Panic attacks
[ ] Racing or scrambled thoughts
[ ] Bad or unwanted thoughts
[ ] Flashbacks/Nightmares
[ ] Muscle tensions, aches, etc.
[ ] Hearing voices/Seeing things not there
[ ] Thoughts of running away
[ ] Paranoid thoughts/Thoughts that someone is watching you, out to get you or hurt you
[ ] Feelings of frustration
[ ] Feelings of being cheated
[ ] Perfectionism
[ ] Rituals of counting things, washing hands, checking locks, doors, stove, etc./Overly concerned about germs
[ ] Distorted body image (believe you are heavier or less attractive than others say you are)
[ ] Concerns about dieting
[ ] Feelings of loss of control over eating
[ ] Binge eating/Purging
[ ] Rules about eating/Compensating for eating
[ ] Excessive exercise
[ ] Indecisiveness about career
[ ] Job problems
[ ] Other:
Previous Treatment
Have you received or participated in previous counseling and/or therapy? [ ] Yes [ ] No
Additional Information:
What did you like/dislike about previous treatment?
What did you learn about yourself through previous counseling/treatment that may help you?
Is there any type of treatment you would like to continue?
Have you had hospital stays for psychological concerns? [ ] Yes [ ] No
Are you currently experiencing thoughts of harming either yourself or someone else?
[ ] Yes [ ] No
Have you in the past experienced thoughts of harming either yourself or someone else?
[ ] Yes [ ] No
Developmental History
Are you aware of any difficulties or complications during the time your mother was pregnant with you? [ ] Yes [ ] No
If yes, explain:
Did you walk, talk, and read on time? [ ] Yes [ ] No
Explain:
Do you feel you have completed normal life milestones (school, career, marriage, children, etc.) at appropriate times?
Are you satisfied at where you are in your life?
If not, where would you like to be?
Medical History
List any current or important past medications
Medication & Dose: Response to Medication:
History of serious childhood illnesses:
Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your lifetime:
Have you experienced any head injuries? [ ] Yes [ ] No
Important Details:
If yes, did you lose consciousness? [ ] Yes [ ] No
Have you experienced convulsions or seizures? [ ] Yes [ ] No
If yes, did you also have a fever? [ ] Yes [ ] No
Explain any allergies you have:
How would you rate your current physical health?
[ ] Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ] Very Poor
What was the date of your last physical or routine health “check up?”
Do you have a primary care physician? [ ] Yes [ ] No
If yes, complete the following:
Name
Address
Phone Number
Family History
Birth Location:
Raised by: [ ] Mother [ ] Father [ ] Step-Mother [ ] Step-Father [ ] Other:
Relationship with parent figures:
(good, fair, poor, close, distant, etc.)
Mother:
Father:
Step-parent:
Other:
List your siblings and describe your relationship with them?
Name
Age
Gender
Nature of Relationship
Any history of neglect, and/or physical, verbal, emotional, spiritual, or sexual abuse?
Any family history of substance abuse, mental illness, suicide, or violence?
Any Additional Family Information:
Social History
Describe your relationship with peers and/or friends?
How would you describe your social support network?
Describe your hobbies/interests:
Describe any cultural concerns:
Educational History
When attending school where you:
[ ] In regular classes [ ] Home Study [ ] Special classes [ ] Advanced classes
[ ] Ever suspended [ ] Placed in alternative school
What is the highest educational level you have completed?
Give any additional important educational information (i.e. Did you like school? Have a learning disability?)
Occupational History
What is your current employment status?
[ ] Employed Full-Time [ ] Employed Part-time [ ] Unemployed [ ] Self-employed
[ ] Student [ ] Other
Are you satisfied with your employment?
If not, why?
Marital History
Which best describes your marital status?
[ ] Married, Date: ______[ ] Never Married [ ] Widowed, Date: _____
[ ] Separated, Date: _____ [ ] Divorced, Date:______
If you are married, please briefly describe nature of your marital relationship:
If you are married, which best describes your marital satisfaction?
[ ] Poor [ ] Fair [ ] Good [ ] Great
Please list any previous marriages/significant relationships including current:
Name
Date
Nature of Relationship
Do you have children? [ ] Yes [ ] No
If yes, complete the following:
First Name
Age
Gender
Nature of Relationship
Are there presently any child custody issues involving you or your family? [ ] Yes [ ] No
Does your family currently have Child Protective Services Involvement? [ ] Yes [ ] No
If yes please complete the following:
Case Worker’s Name:
Phone:
Substance Abuse History
Are you currently or have you ever struggled with substance abuse? (alcohol, tobacco, marijuana, caffeine, or other) [ ] Yes [ ] No
If you answered yes, please complete the following substance abuse history chart.
Substance
Ever Used Yes/No
Age of First Use
Frequency of Use
(Daily, Weekly, Monthly)
Amount Used
How did you use it? (smoked, injected, etc.)
Alcohol
Marijuana
Cocaine or Crack
Heroin
Amphetamines
Club Drugs (Ecstasy, Inhalants, etc.)
Pain Medication (Oxycontin, Vicodin, etc.)
Benzodiazepines
Hallucinogens
Other
Complete the following chart if you have ever received treatment for a substance abuse issue.
Name of Treatment Program
Type of Treatment (Rehab, Intensive Outpatient Program, Partial Hospitalization, Halfway House, Recovery House, Counseling, Methadone, Suboxone)
Date of Treatment (Month, Year)
Outcome (Any Clean time?)
Legal History
Do you currently have any pending criminal charges? [ ] Yes [ ] No
Are you on probation? [ ] Yes [ ] No
Name of Probation Officer and County
Have you ever been arrested/convicted of a crime? [ ] Yes [ ] No:
If yes, complete chart.
List any Arrests/Convictions
Date of Arrests/Convictions
Outcome (Served time, Community Service, Drug/Alcohol Treatment, etc.)
Additional Information
Summarize your goals for counseling/therapy:
What expectations do you have for counseling/therapy?
Name 5 things you would like to change about yourself.
What are your strengths?
What are your weaknesses?
Is there any additional information that you believe it is important for your counselor to know in order to provide you with the best care possible?
______
Signature of client or guardian Date
Informed Consent
Client-Counselor Service Agreement
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Goals of Counseling
There can be many goals for the counseling relationship.Some of these will be long-term goals such as improving the quality of your life, learning to live with mindfulness and self-actualization.Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use.Whatever the goals for counseling, they will be set by the clients according to what they want to work on in counseling.The counselor may make suggestions on how to reach that goal but you decide where you want to go.
Risks/Benefits of Counseling
Counseling is an intensely personal process, which can bring unpleasant memories or emotions to the surface.There are no guarantees that counseling will work for you.Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.
Appointments
Appointments will ordinarily be 45-50 minutes in duration, at a frequency and time we agree on. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24-hour notice, you will be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Confidentiality
Your counselor will make every effort to keep your personal information private.If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware.Your counselor may consult with a supervisor or other professional counselor in order to give you the best service. In the event that your counselor consults with another counselor, no identifying information such as your name would be released. Counselors are required by law or mandatory reporting requirements as well as by ethical obligations to release information or make a report when the client poses a risk to themselves, when the client poses a risk to others, in cases of abuse to children or the elderly, or when client's experience unethical behavior by another therapist/counselor. If your counselor receives a court order or subpoena, she may be required to release some information. In such a case, your counselor will consult with other professionals and limit the release to only what is necessary by law.
Confidentiality in Relationship Therapy
If you and your partner decide on some individual sessions as part of the couples therapy, what you say in individual therapy will be considered part of the couples therapy, and may be discussed in our joint sessions. Do not tell me anything you wish to be kept secret from your partner.
Confidentiality and Group Therapy
The nature of group counseling makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that your counselor cannot guarantee that other group members will maintain your confidentiality. However, your counselor will make ever effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in the group confidential. Your counselor also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.
Confidentiality and Technology
Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Skype, Vsee, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information.Your counselor will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur.Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions.Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions.Should a client have concerns about the safety of their email, your counselor can arrange to encrypt email communication with you.